Cite all applicable group I and group II deficiencies on cases that have been inadvertently effectuated. If correcting the case will result in a change in the disability determination or in the onset, ending or cessation date, you must follow the rules on reopening and revising determinations.

Apply the medical improvement review standard (MIRS), which includes consideration of both medical improvement (MI) and the exceptions to MI, to any adverse reopening that would result in the termination of benefits or in a less favorable ending or cessation date.

With rare exceptions, this means:

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  a determination of allowance or continuance may only be changed (based on medical or vocational factors) to a determination of denial, closed period of disability, or cessation; or

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  an ending date or cessation date may only be changed (based on medical or vocational factors) to a less favorable date, if the case meets one of the group I error exceptions or the group II fraud or similar fault exception to MIRS.

For more information on the effect of MIRS on reopening and revision and exceptions, see DI 27501.005B.4. and DI 28020.000.

If the case contains a group I or group II documentation deficiency, take the following action.

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  Return the case to the adjudicating component by preparing a Request for Corrective Action.

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  Cite the group I or group II documentation deficiency.

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  Include the following statement on the Request for Corrective Action if the deficiency is a group I documentation deficiency:

  We have cited a group I documentation deficiency. If the documentation you obtain changes the disability determination, follow existing adverse reopening procedures. Return the case to the review component for completion of the review.

Refer to QR 04440.250C.2. regarding the application of MIRS in an adverse reopening situation.

NOTE: MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

If the case contains a group I decisional deficiency, take the following actions.

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  Return the case to the adjudicating component by preparing a Request for Corrective action.

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  Cite the group I decisional deficiency.

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  Include the following statement on the Request for Corrective Action when a MIRS group I or group II exception to MI does not apply:

  We have cited a group I decisional deficiency in this case. However, we do not believe the determination can be reopened under the fraud or error exceptions to MIRS. Therefore, no further action is necessary at this time. After your review, return the case to the review component.

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  When an MIRS exception applies, tailor the return to the situation. Remind the adjudicating component to follow the adverse reopening procedures and to return the case to the review component for completion of the review.

If the case contains a group II onset date decisional deficiency, return the case to the adjudicating component by preparing a Request for Corrective Action and advise the adjudicating component to follow existing reopening procedures. Note that MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

If the case contains a group I or group II documentation deficiency, take the following actions.

• •

  Return the case to the adjudicating component by preparing a Request for Corrective Action.

• •

  Cite the group I or group II documentation deficiency.

• •

  Include the following statement on the Request for Corrective Action:

  We have cited a group I (group II) documentation deficiency. If the documentation you obtain changes the disability determination (onset or ending date) to an unfavorable determination (less favorable ending date), follow existing adverse reopening procedures. Return the case to the review component for completion of the review.

Refer to QR 04440.250C.2. regarding the application of MIRS in an adverse reopening situation.

NOTE: MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

If the case contains a group I decisional deficiency, take the following actions.

• •

  Return the case to the adjudicating component by preparing a Request for Corrective Action.

• •

  Cite the group I decisional deficiency.

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  Include the following statement on the Request for Corrective Action if the determination should be unfavorable and an MIRS group I or group II exception to MI does not apply:

  We have cited a group I decisional deficiency in this case. However, we do not believe the determination can be reopened under the fraud or error exceptions to MIRS. Therefore, no further action is necessary at this time. Return the case to the review component for completion of the review.

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  When an MIRS exception applies, tailor the return to the situation. Remind the adjudicating component to follow the adverse reopening procedures and to return the case to the review component for completion of the review.

For review policy on adverse reopening when no appeal is filed, see QR 04440.250C.2.

If the case contains a group II onset date decisional deficiency, return the case by preparing a Request for Corrective Action and advise the adjudicating component to follow existing reopening procedures.

MIRS does not apply to reopening and revision to a later onset date per DI 27501.005B.4.b. and DI 28005.001D.2.c.

MIRS applies to a group II ending or cessation date that is less favorable than the ending or cessation date established in the effectuated determination.

If the case contains a group I or a group II documentation deficiency, take the following actions.

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  Return the case to the adjudicating component by preparing a Request for Corrective Action.

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  Cite the group I or group II documentation deficiency.

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  Include the following statement on the Request for Corrective Action:

  We have cited a group I (group II) documentation deficiency. If the documentation you obtain changes the disability determination (or the cessation date), follow existing reopening procedures. Return the case to the review component for completion of the review.

NOTE: If you propose a less favorable cessation date, you have to establish MI from the last comparison point decision (CPD) to the proposed cessation date to revise the cessation date if no exceptions to MI apply.

See DI 28005.205D.2. for cessation month and error exception cases.

If the case contains a group I decisional deficiency, take the following actions.

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  Return the case to the adjudicating component by preparing a Request for Corrective Action.

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  Cite the group I decisional deficiency.

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  Include the following statement on the Request for Corrective Action:

  We have cited a group I decisional deficiency in this case. Please reopen and revise the determination following existing reopening procedures. Return the case to the review component for completion of the review.

If the case contains a group II decisional deficiency, take the following action.

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  Return the case to the adjudicating component by preparing a Request for Corrective Action.

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  Cite the group II decisional deficiency.

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  Advise the adjudicating component to follow the existing procedures for reopening and revision. (For cessation month and error exception cases, see DI 28005.205D.2.)

NOTE: If you propose a less favorable cessation date, and no exceptions to MI apply, MI from the last CPD to the proposed cessation date would have to be established in order to revise the cessation date.

References

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  For an explanation of reopenings and revisions, see DI 27501.000.

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  For preparation of a revised SSA-831-C3/U3, see DI 27530.000.

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  For an explanation of MIRS and when it applies, see DI 28005.000.

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  For exceptions to MIRS, see DI 28020.000.

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  For preparation of a revised SSA-832-C3/U3 or SSA-833-C3/U3, see DI 28501.000.

If the review component receives notice of a request for reconsideration or the Form SSA-3441-BK (Disability Report – Appeal) while a case is undergoing quality review:

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  associate the SSA-3441-BK or the notice of an appeal with the case;

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  ensure the case receives expedited processing; and

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  send the folder to the field office (FO) upon completion of the quality review. Prepare a Request for FO Assistance if FO development is necessary. Otherwise, use Form SSA-559 (Transmittal Slip for Claims Folders) to route the folder.

If the request for reconsideration was filed in the FO:

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  associate the appeals notice or SSA-3441-BK with the case;

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  ensure the case receives expedited processing;

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  prepare a Request for Corrective Action and send it to the adjudicating component with the folder;

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  instruct the adjudicating component to take corrective action and all reconsideration actions, including the preparation of the SSA-831-C3/U3, SSA-832-C3/U3, and SSA-833-C3/U3, if necessary

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  instruct the adjudicating component to return the case to the review component.

For an explanation of FO actions when a request for reconsideration is filed, see DI 12005.005 – DI 12005.020.

If you receive the request for reconsideration in the review component without the FO processing the request first:

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  prepare a photocopied file;

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  prepare a Request for Corrective Action and send it to the adjudicating component with the photocopied file.

Instruct the adjudicating component to:

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  take all reconsideration actions, including the preparation of the SSA-831-C3/U3, SSA-832-C3/U3, or SSA-833-C3/U3, if necessary;

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  associate the original folder with the photocopied file, in the event of a reversal, before requesting any necessary development of reversal action; and,

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  return the case to the review component before effectuation of the revised determination.

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  send the original case file, with a copy of the Request for Corrective Action, to the FO for their necessary reconsideration action.

For an explanation of FO actions when a request for reconsideration is filed, see DI 12005.005 – DI 12005.020.